A nurse is caring for a 30-year-old client who was brought to the emergency department (ED).

Exhibits

The nurse should determine the assessment findings are consistent with which of the following disease processes?

For each assessment finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.

WBC count in CSF

Muscle weakness

Altered level of consciousness

Kernig sign result

Body temperature at 2105

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

A high white blood cell (WBC) count in cerebrospinal fluid (CSF) is more commonly associated with bacterial meningitis, characterized by a high neutrophil count, low glucose, and high protein levels. it is also seen in encephalitis and reflects the individual cell lines that are affected.

Muscle weakness and altered levels of consciousness can occur in both conditions but are more prominent in encephalitis, which often presents with focal neurological deficits and seizures. The

Kernig sign, a classical sign of meningitis, is a physical examination finding that indicates irritation of the meninges and supports a diagnosis of bacterial meningitis when positive.

An elevated body temperature is common in bacterial meningitis, but it is not exclusive and can be observed in encephalitis as well.

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Correct Answer is B

Explanation

A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.

A. Wear a face shield. B. Wear clean gloves. C. Wear sterile gloves. D. Wear an N95 respirator mask.

Correct Answer is B

Explanation

A. A face shield is necessary when there is a risk of splashes, but not required for simply checking a pulse.
B. Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
C. Sterile gloves are not required for checking a pulse unless performing a sterile procedure.
D. An N95 respirator mask is used for airborne precautions, not necessary for MRSA, which is contact-transmitted.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Correct Answer is B

Explanation

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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